[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5605 Introduced in House (IH)]

<DOC>






115th CONGRESS
  2d Session
                                H. R. 5605

   To amend title XVIII of the Social Security Act to provide for an 
          opioid use disorder treatment demonstration program.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             April 24, 2018

   Mr. Ruiz introduced the following bill; which was referred to the 
 Committee on Energy and Commerce, and in addition to the Committee on 
   Ways and Means, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
   To amend title XVIII of the Social Security Act to provide for an 
          opioid use disorder treatment demonstration program.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Advancing High Quality Treatment for 
Opioid Use Disorders in Medicare Act''.

SEC. 2. OPIOID USE DISORDER TREATMENT DEMONSTRATION PROGRAM.

    Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is 
amended by inserting after section 1866E (42 U.S.C. 1395cc-5) the 
following new section:

``SEC. 1866F. OPIOID USE DISORDER TREATMENT DEMONSTRATION PROGRAM.

    ``(a) Implementation of 5-Year Demonstration Program.--
            ``(1) In general.--Not later than January 1, 2021, the 
        Secretary shall implement a 5-year demonstration program under 
        this title (in this section referred to as the `Program') to 
        increase access of applicable beneficiaries to opioid use 
        disorder treatment services, improve physical and mental health 
        outcomes for such beneficiaries, and to the extent possible, 
        reduce expenditures under this title. Under the Program, the 
        Secretary shall make payments under subsection (f) to 
        participating care teams (as defined in subsection (c)(1)(A)) 
        for providing opioid use disorder treatment services to 
        applicable beneficiaries participating under the Program.
            ``(2) Opioid use disorder treatment services.--For purposes 
        of this section, the term `opioid use disorder treatment 
        services'--
                    ``(A) means, with respect to an applicable 
                beneficiary, services that are furnished for the 
                treatment of opioid use disorders in an outpatient 
                setting and--
                            ``(i) which are supported by the per 
                        applicable beneficiary per month care 
                        management fee under subsection (f); or
                            ``(ii) for which payment may otherwise be 
                        made under this title; and
                    ``(B) includes--
                            ``(i) medication assisted treatment;
                            ``(ii) treatment planning;
                            ``(iii) appropriate outpatient psychiatric, 
                        psychological, or counseling services (or any 
                        combination of such services);
                            ``(iv) appropriate social support services; 
                        and
                            ``(v) care management and care coordination 
                        of opioid use disorder services, as well as 
                        coordination with other physicians and 
                        providers treating the mental and physical 
                        conditions of such beneficiary.
    ``(b) Program Design.--
            ``(1) In general.--The Secretary shall design the Program 
        in such a manner to evaluate the extent to which the Program 
        accomplishes the following purposes:
                    ``(A) Reduces hospitalizations and emergency 
                department visits.
                    ``(B) Reduces the occurrence of overdoses from 
                opioids, including prescription opioid medications as 
                well as illicit opioids.
                    ``(C) Increases use of medication-assisted 
                treatment for opioid use disorders.
                    ``(D) Improves health outcomes of individuals with 
                opioid use disorders, including by reducing the 
                incidence of infectious diseases (such as hepatitis C 
                and HIV).
                    ``(E) Does not increase the total spending on 
                health care services under this title.
                    ``(F) Reduces deaths from opioid poisoning.
                    ``(G) Reduces the utilization of inpatient 
                residential treatment.
            ``(2) Consultation.--In designing the Program, the 
        Secretary shall, not later than 3 months after the date of the 
        enactment of this section, consult with specialists in the 
        field of addiction and clinicians in the primary care 
        community.
    ``(c) Participating Care Teams.--
            ``(1) Definition; selection.--
                    ``(A) Definition.--In this section, the term 
                `participating care team' means an opioid use disorder 
                care team (as defined in paragraph (2)) that is 
                participating under the Program pursuant to selection 
                by the Secretary under subparagraph (B).
                    ``(B) Selection.--Under the Program, the Secretary 
                shall provide for a process for opioid use disorder 
                care teams to apply for participation under the Program 
                as participating care teams and for selecting such 
                teams for such participation.
                    ``(C) Preference.--In selecting opioid use disorder 
                care teams under subparagraph (B) for participation 
                under the Program, the Secretary shall give preference 
                to opioid use disorder care teams that are located in 
                areas with a prevalence of opioid use disorders that is 
                higher than the national average prevalence, as 
                measured by aggregate overdoses of opioids, or any 
                other measure that the Secretary deems appropriate.
            ``(2) Opioid use disorder care teams.--
                    ``(A) In general.--For purposes of this section, 
                the term `opioid use disorder care team' means a group 
                of health care practitioners, or an entity employing or 
                contracting with such health care practitioners, that--
                            ``(i) includes at least one physician who 
                        is providing primary care services or addiction 
                        treatment services to an applicable beneficiary 
                        during the period in which the opioid use 
                        disorder care team is receiving payments under 
                        subsection (f);
                            ``(ii) includes at least one eligible 
                        practitioner (as defined in paragraph (3)(A)), 
                        who may be a physician who meets the criterion 
                        in clause (i); and
                            ``(iii) includes other practitioners--
                                    ``(I) as necessary to deliver 
                                appropriate psychiatric, psychological, 
                                counseling, and social services to 
                                applicable beneficiaries in addition to 
                                the services delivered by the eligible 
                                practitioner; and
                                    ``(II) who only perform services 
                                that such practitioners are legally 
                                authorized to perform under State law.
                    ``(B) Requirements for participation.--In order for 
                an opioid use disorder care team to participate in the 
                Program as a participating care team, each of the 
                practitioners participating on the team shall agree 
                to--
                            ``(i) deliver opioid use disorder treatment 
                        services to applicable beneficiaries who agree 
                        to receive the services;
                            ``(ii) meet minimum standards for quality 
                        required by the Program; and
                            ``(iii) submit to the Secretary, with 
                        respect to each applicable beneficiary for whom 
                        such practitioner provides opioid use disorder 
                        treatment services, data with respect to the 
                        quality standards and the measures defined in 
                        subsection (d) and such other information as 
                        the Secretary determines appropriate to monitor 
                        and evaluate the Program and to determine the 
                        performance of each practitioner for purposes 
                        of the incentive payment under subsection (f), 
                        in such form, manner, and frequency as 
                        specified by the Secretary.
            ``(3) Eligible practitioners; other provider-related 
        definitions and application provisions.--
                    ``(A) Eligible practitioners.--For purposes of this 
                section, the term `eligible practitioner' means, with 
                respect to an applicable beneficiary, a provider of 
                services that--
                            ``(i) participates in the Medicare program 
                        under this title;
                            ``(ii)(I) is authorized to prescribe or 
                        dispense narcotic drugs to individuals for 
                        maintenance treatment or detoxification 
                        treatment; and
                            ``(II) has in effect a registration or 
                        waiver in accordance with section 303(g) of the 
                        Controlled Substances Act for such purpose and 
                        is otherwise in compliance with regulations 
                        promulgated by the Substance Abuse and Mental 
                        Health Services Administration to carry out 
                        such section; and
                            ``(iii) with respect to furnishing opioid 
                        use disorder treatment services to the 
                        applicable beneficiary, participates in an 
                        opioid use disorder care team, which is a 
                        participating care team.
                    ``(B) Addiction specialists.--For purposes of 
                paragraph (2)(C), the term `addiction specialist' means 
                a physician that possesses expert knowledge and skills 
                in addiction medicine, as evidenced by--
                            ``(i) certification by the American Society 
                        of Addiction Medicine or the American Board of 
                        Addiction Medicine;
                            ``(ii) subspecialty certification in 
                        addiction medicine by the American Board of 
                        Preventive Medicine;
                            ``(iii) subspecialty certification in 
                        addiction psychiatry by the American Board of 
                        Psychiatry and Neurology;
                            ``(iv) a certificate of added qualification 
                        in addiction medicine conferred by the American 
                        Osteopathic Association; or
                            ``(v) completion of an accredited residency 
                        or fellowship in addiction medicine or 
                        addiction psychiatry.
    ``(d) Quality and Other Reporting Requirements.--
            ``(1) Adoption and development of standards and performance 
        measures.--Not later than 9 months after the date of the 
        enactment of this section, the Secretary, in conjunction with 
        stakeholders (including clinicians in the primary care 
        community and the field of addiction medicine), shall adopt or 
        develop (or an appropriate entity with which the Secretary 
        contracts shall develop) quality standards and methods of 
        assessing the quality of care to ensure a minimum level of 
        quality of care and to determine whether the services furnished 
        by participating care teams are achieving the purposes 
        described in subsection (b)(1). For purposes of adopting or 
        developing standards for payments under subsection (f)(1) and 
        for purposes of adopting or developing methods for assessing 
        performance for the incentive payments under subsection (f)(2), 
        the Secretary may consider existing clinical guidelines for the 
        treatment of opioid use disorders and standards or measures 
        applied for use under the Medicaid program under title XIX. 
        Standards and assessment methods shall address the following 
        outcomes and performance criteria:
                    ``(A) Patient engagement in treatment.
                    ``(B) Retention in treatment.
                    ``(C) Provision of evidence-based medication-
                assisted treatment.
                    ``(D) Any other criteria the Secretary deems 
                appropriate.
            ``(2) Submission.--Each participating care team shall 
        submit to the Secretary, in such form, manner, and frequency 
        specified by the Secretary, data with respect to such standards 
        and assessment methods and such other information as the 
        Secretary determines appropriate to monitor and evaluate the 
        Program and to determine the performance of such team for 
        purposes of the incentive payment under subsection (f)(2).
    ``(e) Participation of Applicable Beneficiaries.--
            ``(1) Applicable beneficiary defined.--In this section, the 
        term `applicable beneficiary' means an individual who--
                    ``(A) is entitled to benefits under part A and 
                enrolled for benefits under part B;
                    ``(B) is not enrolled in a Medicare Advantage plan 
                under part C;
                    ``(C) has a diagnosis for an opioid use disorder; 
                and
                    ``(D) meets such other criteria as the Secretary 
                determines appropriate.
        Such term shall include an individual who is dually eligible 
        for benefits under this title and title XIX if such individual 
        satisfies the criteria described in subparagraphs (A) through 
        (D).
            ``(2) Voluntary participation.--An applicable beneficiary 
        may participate in the Program on a voluntary basis and may 
        terminate participation in the Program at any time.
            ``(3) Services.--In order to participate in the Program, an 
        applicable beneficiary must agree to receive opioid use 
        disorder treatment services from a participating care team. An 
        applicable beneficiary may only receive services supported by 
        the Program from one participating care team during any one 
        calendar month. Participation under the Program shall not 
        affect coverage of or payment for any other item or service 
        under this title for the applicable beneficiary.
            ``(4) Beneficiary access to services.--Nothing in this 
        section shall be construed as encouraging providers to limit 
        applicable beneficiary access to services covered under this 
        title and applicable beneficiaries shall not be required to 
        relinquish access to any benefit under this title as a 
        condition of receiving services from a participating care team.
    ``(f) Payments.--
            ``(1) Per applicable beneficiary per month care management 
        fee.--
                    ``(A) In general.--The Secretary shall establish a 
                schedule of per applicable beneficiary per month care 
                management fees. Such a per applicable beneficiary per 
                month care management fee shall be paid to a 
                participating care team in addition to any other amount 
                otherwise payable under this title to the practitioners 
                participating with the team or, if applicable, the 
                entity with respect to such team employing or 
                contracting with such practitioners. A participating 
                care team may use such per applicable beneficiary per 
                month care management fee to deliver additional 
                services to applicable beneficiaries, including 
                services not otherwise eligible for payment under this 
                title.
                    ``(B) Application.--In carrying out subparagraph 
                (A), the Secretary shall--
                            ``(i) consider the costs that participating 
                        care teams are expected to incur in delivering 
                        high-quality opioid use disorder care services 
                        that are not covered by payments otherwise 
                        payable to the teams under this title;
                            ``(ii) pay a higher per applicable 
                        beneficiary per month care management fee for 
                        an applicable beneficiary who receives more 
                        intensive treatment services from a 
                        participating care team and who is appropriate 
                        for such services based on clinical guidelines 
                        for opioid use disorder care;
                            ``(iii) pay a higher per applicable 
                        beneficiary per month care management fee for 
                        the month in which the applicable beneficiary 
                        begins treatment with a participating care team 
                        than in subsequent months, to reflect the 
                        greater time and costs required for the team to 
                        plan and initiate treatment, as compared to 
                        maintenance of treatment; and
                            ``(iv) pay higher per applicable 
                        beneficiary per month care management fees for 
                        participating care teams that include an 
                        addiction specialist who is either delivering 
                        services directly to applicable beneficiaries 
                        or providing consulting support to those 
                        practitioners participating with such teams who 
                        are delivering services to applicable 
                        beneficiaries.
            ``(2) Incentive payments.--Under the Program, the Secretary 
        shall establish a performance-based incentive payment, which 
        shall be paid to participating care teams based on the 
        performance of such teams with respect to standards and 
        assessment methods adopted or developed by the Secretary under 
        subsection (d) and with respect to which the teams report under 
        such subsection.
    ``(g) Multipayer Strategy.--In carrying out the Program, the 
Secretary shall encourage other payers to provide similar payments and 
to use similar quality standards and methods of assessment as applied 
under the Program. The Secretary may enter into a memorandum of 
understanding with other payers to align the methodology for payment 
provided by such a payer related to opioid use disorder treatment 
services with such methodology for payment under the Program.
    ``(h) Evaluation.--
            ``(1) In general.--The Comptroller General of the United 
        States shall conduct an intermediate and final evaluation of 
        the program. Each such evaluation shall determine the extent to 
        which each of the purposes described in subsection (b) have 
        been accomplished under the Program. Each evaluation shall also 
        determine the extent to which the structure and requirements of 
        the Program facilitated or impeded the participation of 
        practitioners in the program, the participation of 
        beneficiaries with opioid use disorder, and the delivery of 
        high-quality opioid use disorder treatment services.
            ``(2) Reports.--The Comptroller General of the United 
        States shall submit to the Secretary and Congress--
                    ``(A) a report with respect to the intermediate 
                evaluation under paragraph (1) not later than 3 years 
                after the date of the implementation of the Program; 
                and
                    ``(B) a report with respect to the final evaluation 
                under paragraph (1) not later than 6 years after such 
                date.
    ``(i) Funding.--
            ``(1) Administrative funding.--For the purposes of 
        implementing, administering, and carrying out the Program 
        (other than for purposes described in paragraph (2)), there 
        shall be transferred to the Secretary for the Center for 
        Medicare & Medicaid Services Program Management Account from 
        the Federal Supplementary Medical Insurance Trust Fund under 
        section 1841 $5,000,000.
            ``(2) Care management fees and incentives.--For the 
        purposes of payments under subsection (f), there shall be 
        transferred to the Secretary such sums as are necessary from 
        the Federal Supplementary Medical Insurance Trust Fund under 
        section 1841 for each of fiscal years 2021 through 2025.
            ``(3) Availability.--Amounts transferred under this 
        subsection for a fiscal year shall be available until expended.
    ``(j) Waivers.--The Secretary may waive any provision of this title 
that conflicts with or impedes the implementation of the provisions of 
this section.''.
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